Holiday planning is usually about everyone but ourselves. We buy presents for everyone else, we plan special meals, we rearrange work and other social events, and we usually cut way back on time for ourselves to make room for the onslaught of others.

This holiday sex tip is part self-loving and part survival tip. One of the reasons many of us lose it over the holidays is a lack of balance. We don’t just cut out some of our “me” time, we take no time for ourselves, or our romantic partners, at all.

This week make plans for at least one illicit rendezvous with your partner (or yourself) during the holidays. If you have a lot of family obligations that’s no excuse. You can always find five minutes to hide in a bathroom, closet, or the car.

Your plan should be very detailed, leave nothing to chance:

• Pick a specific date and a specific time
• Think about how long you’ll have for your date. Make it reasonable, keep it short
• Choose a location that you know will be available
• Decide what you want to do
• Consider any props: outfits, safer sex gear, sex toys, and put them away somewhere you can easily get them on the specified day.

If you’re making a plan for you and a partner, you may or may not want to let them in on the plan. If you don’t, you run the risk of them “not being in the mood” and being distracted by holiday stress. If you do let them in you ruin a perfectly good sex surprise.

You might want to plan a phone sex date just before leaving work on the 24th. You might want to plan a late night romp after the presents are wrapped but before the kids wake up on the 25th. It might be a date with yourself sometime in the middle of a long day surrounded by extended family.

Whatever you choose, consider this a complete mental health holiday, and even if it’s only ten minutes, appreciate at least ten minutes of emotional, physical, and spiritual rejuvenation.

Have fun!

The holiday season is one of the few times each year when we are encouraged to ask for things we want. But there are limits on what we’re “supposed” to ask for. New clothes? Yes. A cordless drill? Sure. A little extra time in the oral sex department? Ummm…probably not.

One of the obvious problems is that we’re rarely encouraged to talk openly with our partners about our sexual desires. Sex, we’re told, comes naturally. Which means we should just know what our partner wants and needs at any given moment. But anyone who has had sex, will know this isn’t true.

Today’s tip asks you to add to your holiday wish list. You can still lust after the complete series box set of Buffy the Vampire Slayer, or a new I Pod, but I want you to keep digging, past the consumer desires, and into the larger private repository of your sexual interests. What would you love to try with your partner sometime over the holidays? A new position? A sex toy? Fantasy role playing? Simply more time to have the sex you are already having?

Come up with a list of three things* you’d love to do. Here are some guidelines: The first activity should be something you’d like to do to your partner. The second should be something you want your partner to do to you The last activity is something new for both of you, or at least something you haven’t done together.

You can tell your partner you’re doing this, and ask them to do the same. Or take control of the sled this holiday season, and see where it takes you. Remember to establish good ground rules about sharing sexual wishes, including no judgment and no guilt for saying no or making changes to the wishes.

*If you celebrate Hannukah, or want to pay homage to the festival of lights, you can come up with eight activities and spread them out over eight days.

Have fun!

It’s true. Or so says the completely unscientific but -- according to the New York Times -- expert opinion of SexHelp.com. I’m outing myself by displaying my test results on this very page. It’s small so you might not see that I’m a “10” on the sex addict scale. I was pleased to see that I beat out fellow sex addict Dr. Petra Boynton (she’s only a 9, but she’s British).

As you’ve probably read of late Petra and I are in good company. Yesterday actor David Duchovny left his sex addiction rehab program, presumably bolstered after an intense few weeks of being told to masturbate less, stop fantasizing about sex, only have sex when he feels an emotional connection with his partner, and for goodness sake, don’t use sex to make yourself feel good or express something about your identity (also no sex toys, sex outdoors, BDSM, etc… etc…).

So why am I sharing such a personal fact with so many people I barely know? Well it’s not an elaborate ploy to get more dates and feed my addiction. It’s more of a response to the sex addiction literature I’ve been reading and the absolutely shameful news coverage of the two most recent sex addiction media events (first Duchovny, then the anal-bead-heralded movie premiere of Choke).

Blogs aren’t always conducive to elaborate arguments, so if you’re interested in a reading why everything you know about sex addiction is wrong, there’s lots to sink your teeth into. Here let’s just take two examples.

First up this quote from a CNN.com story published following Duchovny’s disclosure that he was seeking counseling for his “sex addiction”:

'We're seeing it with epidemic proportions now, particularly with regards to cybersex,' said Mark Schwartz, psychologist and former director of the Masters and Johnson Institute in St. Louis, Missouri. 'There isn't a week that goes by where I don't get two calls' about sex addiction.

A St. Louis psychologist who was affiliated with a sex therapy institute receiving two calls a week is hardly an epidemic (and even according to some of the sex addiction people the numbers haven’t changed from what they claim are the 6-10% of Americans who are sex addicts). And any clinician who makes broad social statements based not even on their clinical experience but the anecdotal evidence of their phone records really needs to brush up on their ethical obligations as a mental health professional.

Next up is this gem from a peer reviewed journal article written for nurses about women and sex addiction:

Addiction in women is a growing problem in the United States and is recognized as a very serious disease. Today researchers are able to document the neurochemistry of addiction in the brain. It has been found that sexual activity can create a “high” equal to that of crack cocaine.

Sounds pretty scary. The problem is that it is an inaccurate description of the actual research and it takes that mistake and further confuses it with a leap in logic. It’s true that some studies show that brain activity (although not neurochemistry as suggested in the quote) is present in similar areas during cocaine craving and orgasm. But this in no way means that the experiences are equal.

So what have most of the major news organizations done when called to report on a concept that still hasn't been accepted into either of the bibles of world mental health professionals? Well they go right to the people who invented the term; the sex addiction and recovery industry. Turning to “sex addiction counselors” as experts on human sexuality is like turning to the Ministry of Truth for an expert opinion on where we came from. Without agreement from mental health professionals, without a solid basis of evidence-based research, and in many cases without a grasp of sexological research the sex addiction industry has established itself as a necessary body to treat an illness that only they agree exists.

This is not to say that there aren’t people who struggle with out of control sexual behaviors. People lose relationships, families, jobs, and more because they feel like they can’t control a particular behavior. The problem is not that the sex addiction industry is making up the pain, the problem is that by mixing morality and ambiguity into their theory they actually reduce their chances of helping people in pain deal with their problematic behaviors. Quick fixes are great for selling books and winning elections. But they leave most of us regular folks high and dry in the end.

And so I’ve decided to come out as a sex addict. I seem to be coping fine. I work three jobs, I volunteer my time with several organizations, and if I weren’t Jewish I’m sure I’d go to church with some regularity. I even occasionally see my family (never as much as they like, but I blame that on the addiction). Sure I need help, and I never hesitate to avail myself of mental health services when in need. But I hope I can set an example that it is possible to be labeled a sex addict by a website and still be doing okay. Maybe I should make t-shirts.

**I hesitated before giving this post the title I gave it. I think there’s a tendency among those who don’t agree with the sex addiction model to make fun of the people who get labeled or label themselves as sex addicts. These people may be in genuine crisis and instead of getting the support they need they're being led up the garden path (either by people who know better or should know better). I didn’t want to increase their pain by seeming to make fun of them. But in the end, after reviewing the “research” the terminology is so ludicrous that I felt I had no choice. Plus I bet there isn’t a group that Petra Boynton belongs to that I wouldn’t be proud to join.

Despite a wide acceptance by the media, there is no agreement among bio-medical and social science researchers regarding sex addiction. Some debate the proper definition and others believe that the very idea of an addiction to sex is misguided and not helpful to those who need help. There is general agreement that some people have problems controlling their own sexual behaviors despite many efforts and obvious negative consequences of the behaviors. These problems may be mild or seriously debilitating. While there is no debate that some people engage in out-of-control sexual behavior, there is enormous disagreement about whether or not such behavior should be called sex addiction.

The 'Popular Definition' of Sex Addiction

You may have read about sex addiction in the media, either in the context of one celebrity having a sex addiction, or in an article about how the Internet is turning us all into sex addicts. The definition of sex addiction most often used in this context developed out of a vocal movement of therapists, community organizations, and religious groups led by Patrick Carnes who first articulated his vision of “sex addiction” in his book Out of the Shadows: Understanding Sexual Addiction.

On Carnes’ website he describes sex addiction this way:

"Sexual addiction is defined as any sexually-related, compulsive behavior which interferes with normal living and causes severe stress on family, friends, loved ones and one's work environment.

Sexual addiction has been called sexual dependency and sexual compulsivity. By any name, it is a compulsive behavior that completely dominates the addict's life. Sexual addicts make sex a priority more important than family, friends and work. Sex becomes the organizing principle of the addict's lives. They are willing to sacrifice what they cherish most in order to preserve and continue their unhealthy behavior."

The main feature of Carne’s definition of sex addiction is inability to control one’s sexual behavior, which also includes thinking and fantasizing about sex too much. In this formulation sexual activity and even the desire for it creates a “high” which Carnes and his colleagues equate with a drug high. The addiction is evidenced by the fact that people will engage in risky, hurtful behaviors despite understanding the negative consequences that will result.

There are many problems with the concept of sex addiction. Most importantly, there is not enough empirical research to back up this definition and the majority of “evidence” given by those who subscribe to this definition consist of stories from therapists who, we’re told, have worked with clients and successfully treated them.

How Common Is Sex Addiction?

If you’re someone who is worried about their ability to control sexual thoughts, desires, and activities, this may be something you want to know, but unfortunately there isn’t a good answer. First, it’s impossible to know how many people share an experience (like sex addiction) if we don’t agree on what that experience is. Secondly, the unscientific estimates vary wildly from therapist to therapist and from one newspaper article to the next. Estimates from the sex addiction camp range from 6–10% to 45% of the American population having a sex addiction.

Causes of Sex Addiction

Theories as to what causes sex addiction or out-of-control sexual behaviors depend to some extent on the definition one subscribes to. Causes that have been cited (but never proven) include psychological causes (e.g. inability to control impulses, sex as a way of dealing with depression or anxiety, sex as a coping mechanism), bio-medical (faulty neurotransmitter regulation, in rare cases some neurological or psychiatric disorders) and social/relational (problems with intimacy, communication problems, discrepancies of sexual desire, increased access to sexually explicit material). Many sex addiction writers often suggest a relationship between sex addiction and childhood sexual abuse, and between sex addiction and current drug abuse.

Other Definitions of Sex Addiction

Researchers who reject the idea of an addiction model have used other terms over the years, including:

• compulsive sexual behavior
• impulse control disorder
• hypersexaulity
• nymphomania
• styriasis
• out-of-control sexual behaviors

From the perspective of an individual struggling with a behavior they feel like they can’t control, what you call it may seem less important than how to stop it. But definitions are important as they often influence treatment. For example if you define sex addiction by the amount of sex you have, treatment will be designed to reduce your frequency of sexual behavior. If you define sex addiction as an inability to experience intimacy, treatment will try to build one’s capacity for sexual intimacy.

I Don’t Care About Definitions, I Think I’m a Sex Addict

Broadly speaking, if you are struggling with out-of-control sexual behaviors and think you may be a sex addict, it is always a good idea to consult with a licensed therapist. A lucrative industry has developed around the sex addiction model and you can easily find a therapist who is "certified" to treat sex addictions. The problem is that these therapists may not have training in sex therapy and may, in fact, have no education in human sexuality. While many therapists deal with sexual issues with clients, if you're looking for someone who has specialized in sexuality you should seek out a certified sex therapist. At a minimum make sure you understand the training and credentials of whoever you work with before engaging in treatment.

Postmenopausal women who have lost interest in sex may be able to bring their libidos back to life with a testosterone patch, according to new research published Wednesday in The New England Journal of Medicine.

However, the use of the male hormone to boost sex drive in women may not be risk-free. Four women in the study who were taking testosterone developed breast cancer, but none of the women on placebo did. It’s not clear whether this was a statistical blip or a warning sign that excess testosterone could cause or spur the growth of a malignancy. Some women also reported excess hair growth, although none stopped using the hormone for this reason.

Susan R. Davis, MD, PhD, of Monash University in Australia, and colleagues in the United States, Canada, and Sweden, evaluated two different doses of testosterone delivered by Procter & Gamble Pharmaceuticals’ Intrinsa patch. In 2004, a U.S. Food and Drug Administration (FDA) panel gave Intrinsa the thumbs down and called for larger, longer studies to ensure that the medication was safe, in addition to proving that it actually helped women’s sex lives.

As the new findings show, it did. Wearing the higher-dose testosterone patch boosted a woman’s “satisfying sexual experiences” by an average of 2.1 times every four weeks, compared to an increase of just 0.7 such experiences for women taking a placebo. Both testosterone doses used in the study seemed to increase desire and decrease distress.

“Although the change in activity is modest, that’s something that is appropriate and I think most women would be more than happy with it,” says study coauthor Sheryl A. Kingsberg, PhD, chief of behavioral medicine at University Hospitals Case Medical Center in Cleveland. “They wanted to return to the level of desire they had in their premenopausal years, and that’s what they got.” Before starting treatment, the women in the study had been having satisfying sex about twice a month on average, Kingsberg points out; the higher-dose patch increased that to once a week.

“For most women and providers of health care for women, that modest benefit is clinically meaningful,” agrees North American Menopause Society president JoAnn V. Pinkerton, MD, a professor of obstetrics and gynecology at the University of Virginia, in Charlottesville, who did not participate in the study.

Some women lose interest in sex during and after menopause, due in part to the drop in estrogen that comes with the “change of life.” While taking estrogen can increase lubrication and possibly restore a woman’s sex drive, hormone replacement is now understood to up the risk of heart disease and stroke. Many physicians prescribe testosterone instead, although there is currently no testosterone product that’s FDA–approved for treating women with “hypoactive sexual desire disorder.” The European Union has approved Intrinsa, but only for women who have had their ovaries removed, a procedure also known as surgical menopause.

In the current study, 814 women who had undergone either surgical menopause or natural menopause were randomly assigned to use daily a placebo patch or an Intrinsa patch containing either 150 or 300 micrograms of testosterone. The trial lasted for a year, and a subset of women was followed for an additional year. Procter & Gamble Pharmaceuticals sponsored the study and helped design the trial as well as collect and analyze the data.

“Based on these data and other studies we’ve conducted, we are continuing our talks with [the] FDA to explore new opportunities and pathways forward,” says Procter & Gamble spokesperson, Tom Milliken.

One of the women on the 300-microgram dose was diagnosed with breast cancer three months after the study ended; three others in the testosterone groups were diagnosed with the disease between 4 and 12 months after treatment began.

“We do not know if the testosterone patch contributed to proliferation or metastasis of the breast cancer in women diagnosed in the earlier months of the study, potentially affecting their long-term survival,” says Leslie R. Schover, PhD, a behavioral scientist at the University of Texas M.D. Anderson Cancer Center, in Houston, who recently wrote an article analyzing research on testosterone for low libido. “A valid safety study needs at least a five-year follow-up period in a large, randomized trial. If women use Intrinsa without such a trial, I believe they are risking their lives to gain a very modest increase in sexual desire.”

But Dr. Davis says she is not concerned about the increased breast cancer risk seen in the study. Four breast cancer diagnoses among 814 women during a two-year period “is not unexpected,” she says, and given that twice as many study participants were taking testosterone than were on placebo, “it is probably a chance finding that they were in the two treatment groups.”

Many doctors who treat postmenopausal women—and prescribe testosterone off-label to some of them—say a treatment tailored to women is sorely needed and would probably be safe with short-term use. “We don’t have enough safety data to say it’s safe for long-term use, but I think short-term, the benefits clearly outweigh the risks,” Dr. Pinkerton says.

But some experts warn that a pill or patch isn’t always the answer to a sexual problem.

“For women there are so many other things that can contribute to sexual issues, starting from the fact that the most important sex organ is the brain,” says Marcie Richardson, MD, director of the Harvard Vanguard Menopause Survey in Boston. “I’m glad that people are trying to sort this out with good objective evidence, but I hope we don’t fall victim to the notion that this is all about medication, because it’s not.”

Navigation

• Introduction
• Risk Factors
• Lifestyle or Psychological Causes
• Physical Causes
• Prognosis
• Diagnosis
• Treatment
• Lifestyle Changes
• Medications
• Injections or Topical Treatments
• Other Treatments
• Natural Remedies

Yohimbine (Yocon, Yohimex) is derived from an herbal remedy. It appears to boost erectile function by improving blood flow. Studies have been inconclusive about its benefits, but a recent analysis of seven trials reported that between 34% and 75% of men achieved favorable results when taking 5 mg to 10 mg. The American Urologic Association does not recommend yohimbine for treating impotence, although some experts believe it is an inexpensive and reasonable option for some men. Yohimbine is available over the counter as an herbal remedy. It is not government regulated and brands vary in effectiveness and quality.

Side effects include nausea, insomnia, nervousness, and dizziness. Large doses of yohimbine can increase blood pressure and heart rate. One death has been reported from taking tablets of the standard dosage (5.4 mg). More rigorous studies are needed to confirm its effectiveness, and men suffering from anxiety or hypertension are cautioned against its use. To boost success rates, one study indicated that adding L-arginine, an amino acid, may be helpful.

Other Alternative Agents

Many alternative agents are marketed for impotence. Examples include the following:

• The Asian herbal remedies, gingko and ginseng, have been used to stimulate sexual function, although studies on these agents have been small and have had mixed results. One small study reported good results with Argin-Max, which contains a mix of vitamins and natural substances (L-arginine, ginseng, ginkgo). L- arginine, an amino acid, increases production of nitric oxide, a substance that relaxes blood vessels and promotes erections. Gingko, ginseng, and l-arginine can all have side effects, and the products containing them are not regulated.
• Many others are marketed for this condition. Very few have been studied and some can be harmful.

Warnings on Alternative Remedies Used for Erectile Dysfunction

Alternative or natural remedies are not regulated and their quality is not publicly controlled. In addition, any substance that can affect the bodys chemistry can, like any drug, produce side effects that may be harmful. There have been a number of reported cases of serious and even lethal side effects from so-called natural products.

Some so-called natural remedies have been found to contain standard prescription medication. Most reported problems occur in herbal remedies imported from Asia, with one study reporting a significant percentage of such remedies containing toxic metals. Even if studies report positive benefits, most, to date, are very small. In addition, the substances used in such studies are, in most cases, not what are being marketed to the public.

The following website is building a database of natural remedy brands that it tests and rates. Not all are yet available (www.consumerlab.com).

The Food and Drug Administration has a program called MEDWATCH for people to report adverse reactions to untested substances, such as herbal remedies and vitamins (800-332-1088).

The following are some alternative remedies used for erectile dysfunction.

Gamma-Butyrolactone (GBL). GBL is found in products marketed for improving sexual function (Verve, Jolt). This substance can convert to a chemical that can cause toxic and life-threatening effects, including seizures and even coma.

Ginseng. Ginseng has hormonal qualities and should not be used with estrogen. It has also been associated with a hypoglycemia (low blood sugar) and a higher risk for uterine bleeding. It may produce manic episodes, particularly in people on antidepressants. Of note, a great number of ginseng products have been found to contain little or no ginseng. Of particular concern are reports of pesticide and other toxic contaminants in many ginseng products. In one analysis, only nine out of 22 brands did not contain major contaminants. Among the brands that did not contain contaminants were Celestial Seasoning, Centrum, Ginsana, Walgreen's, and Root to Health American Ginseng.

Gingko. Although the risks for gingko appear to be low, there is an increased risk for bleeding at high doses and interaction with high doses of vitamin E, anti-clotting medications, aspirin, or other NSAIDs. Large doses have also been known to cause convulsion. Commercial gingko preparations have also been reported to contain colchicine, an agent that can be harmful in pregnant women and people with kidney or liver problems. It should be further noted that in a 2002 study one-third of 26 brands tested did not contain enough active ingredients to provide any effects at all.

L- arginine (also called arginine). Arginine may cause gastrointestinal problems. It can also lower blood pressure and change levels of certain chemicals and electrolytes in the body. It may increase the risk for bleeding. Some people have an allergic reaction to it, which in same cases may be severe. It may worsen asthma.

Aphrodisiacs. Aphrodisiacs are substances that are supposed to increase sexual drive, performance, or desire. Some examples include the following:

• Viramax is a well-marketed product that contains yohimbine and three herbal aphrodisiacs: catuaba, muira puama, and maca. It has not been proven to be either effective or safe, and interactions with medications are unknown.
• Spanish fly, or cantharides, which is made from dried beetles, is the most widely-touted aphrodisiac but can be particularly harmful. It irritates the urinary and genital tract and can cause infection, scarring, and burning of the mouth and throat. In some cases, it can be life threatening. No one should try any aphrodisiac without consulting a physician.

Other Alternative Products Marketed for Erectile Dysfunction. Vinarol is an over-the-counter supplement that has been recalled after reports that it contains the same ingredients as found in Viagra. Of note, herbal supplements sold as Viagro and Vaegra have no association with Viagra.

Navigation

• Introduction
• Risk Factors
• Lifestyle or Psychological Causes
• Physical Causes
• Prognosis
• Diagnosis
• Treatment
• Lifestyle Changes
• Medications
• Injections or Topical Treatments
• Other Treatments
• Natural Remedies

Vacuum devices, or external management systems, are effective, safe, and simple to use for all forms of impotence except when severe scarring has occurred from Peyronies disease. Devices include Erecaid, Catalyst, and the VED pump and are available over the counter.

Using the Device. Patients must receive thorough instructions in the proper use of such devices. They typically work as follows:

• The man places the penis inside a plastic cylinder.
• A vacuum is created, which causes blood to flow into the penis, thereby creating an erection.
• A band is tightly secured around the base of the penis, which retains the erection, and the cylinder is removed.
• It takes about three to five minutes to produce an erection.

Lack of spontaneity is this methods only major drawback. The erection involves only part of the penis shaft, and the process will certainly seem peculiar in the beginning. When these psychological obstacles are overcome, many couples find the result highly satisfactory.

Success Rates. Studies have found that success with the vacuum device is equal to other methods. Between 56% and 67% of men using it reported the device to be effective. In one study of men who had used the vacuum device for many years, almost 79% reported improvement in their relationships with their sexual partners, and 83.5% said they had intercourse whenever they chose. Nevertheless, dropout rates are high. In one 1999 study, for example, the overall drop out rate was 65%. Even in a high-success group, over half stopped using it.

Side Effects. Side effects include blocked ejaculation and some discomfort during pumping and from use of the band. Minor bruising may occur, although infrequently. It is very important to use a medically approved pump. There have been reports of injury from vacuum devices bought through catalogues that do not have a pressure-release valve or other safety elements.

Venous Flow Controllers

Vacuum-less devices that trap blood within the penis are also available. They are called venous flow controllers or simple constricting devices. These devices are typically rubber or silicone rings or tubes (e.g., Actis) that are placed at the base of the erect penis to trap the erection. They can be used by men who can achieve erections but lose them easily. These devices should not be used for longer than 30 minutes or lack of oxygen can damage the penis, and they should not be used by patients who have bleeding problems or are taking anticoagulants (blood thinners).

Penile Implants

Penile implants are available for men who fail less invasive treatments. More than 200,000 implant procedures were performed between 1982 and 1989, and men have reported high rates of satisfaction. Nevertheless, this is now the least popular therapy for erectile dysfunction.

Three types of surgical implants are currently being used for the treatment of erectile dysfunction:

• A hydraulic implant consists of two cylinders placed within the erection chambers of the penis and a pump. The pump releases a saline solution into the chambers to cause an erection, and removes the solution to deflate the erection.
• A penile prosthesis is composed of two semi-rigid but bendable rods that are placed inside the erection chambers of the penis. The penis can then be manipulated to an erect or non-erect position.
• A third implant uses interlocking soft plastic blocks that can be inflated or deflated using a cable that passes through them.

There appear to be no long-term immune problems related to the silicon or other materials in the devices.

Limitations. Erectile tissue is permanently damaged when these devices are implanted and procedures are irreversible. Although uncommon, mechanical breakdown can occur, or the device can slip or bulge, especially if the patient coughs or vomits vigorously after the operation. In addition, a less than optimal quality of erection may result. (Using the MUSE system may restore or improve the function of a penile prosthesis in patients with a failed device.)

Complications. Infection is the major concern with these devices. Redness and fever often accompany a full-blown infection. Any intermittent pain that continues to occur after an implant may be an indicator of a low-grade infection. If the infection can be caught early enough, implant failure can be prevented. Most infections are treated with antibiotics for at least 10 to 12 weeks. If antibiotics fail, a surgical exchange, in which the infected implant is simultaneously replaced with a new one, should be considered. This is a complex procedure, but some surgeons have reported a 90% success rate. Coatings with specific antibiotics are being investigated and studies are reporting very low infection rates. Long-term effects are unknown.

Vascular Surgery

For men whose impotence is caused by damage to the arteries or blood vessels, vascular surgery might be an option. Two types of operations are available: revascularization (or bypass) surgery, and venous ligation. The American Urologic Association stresses that vascular surgery is still investigative.

Revascularization. The revascularization procedure usually involves taking an artery from a leg and then surgically connecting it to the arteries at the back of the penis, bypassing the blockages and restoring blood flow. In a related procedure called deep dorsal vein arterialization, a penile vein is used for the bypass. Young men with local sites of arterial blockage or those with pelvic injuries generally achieve the best results. In studies of selected patients there was improvement in erectile dysfunction in 50% to 75% of men after five years.

Venous Ligation. Venous ligation is performed when the penis is unable to store a sufficient amount of blood to maintain an erection. This operation ties off or removes veins that are causing an excessive amount of blood to drain from the erection chambers. The success rate is estimated at between 40% and 50% initially, but drops to 15% over the long term. It is important to find a surgeon experienced in this surgery. In a variation of this technique called venous ablation, ethanol is injected into the deep dorsal vein, the main vein that drains blood from the penis. The ethanol causes scarring that closes off smaller veins and prevents blood leakage, thereby bolstering erectile function. In a small trial in 10 men with severe impotence, half maintained erectile function two to three years after the procedure.

Navigation

• Introduction
• Risk Factors
• Lifestyle or Psychological Causes
• Physical Causes
• Prognosis
• Diagnosis
• Treatment
• Lifestyle Changes
• Medications
• Injections or Topical Treatments
• Other Treatments
• Natural Remedies

Penile injections have now largely been replaced by oral medications, specifically sildenafil. Nevertheless, injection and topical (skin) therapies employ various agents that have properties that help achieve erection, even in many men who do not succeed with sildenafil. The standard agents used in injections or topical administration include the following:

• Alprostadil.
• Phentolamine.
• Papaverine.

Although any or all of these agents are very effective, injections or other invasive methods of administration are awkward and uncomfortable. Topical forms of some of these agents are showing promise.

Treatments Using Alprostadil

Alprostadil is derived from a natural substance, prostaglandin E1, and acts by opening blood vessels. It is an effective treatment for some men. It can be administered in three ways:

• By injection into the erectile tissue of the penis (Caverject, Edex).
• By a device that administers the drug through the urethra (MUSE system).
• In a topical cream (Topiglan, Alprox-TD) applied directly to the penis. Studies are suggesting that this approach may prove to be effective and very acceptable. FDA approval is pending at this time.

Candidates. Regardless of how it is administered, alprostadil works in many men with a wide range of medical disorders related to erectile dysfunction, including the following:

• Diabetes.
• Prostate cancer treatments. Early use of alprostadil injections after treatment, particularly when followed by oral Viagra, may be very helpful for men being treated for prostate cancer.
• Men who are taking nitrates.
• Injury.
• Alprostadil is not an appropriate choice for the following individuals:
• Men with severe circulatory or nerve damage.
• Men with bleeding abnormalities or men who are taking medications that thin the blood, such as heparin or warfarin.
• Men with penile implants.

Side Effects of Most Alprostadil Methods . Certain side effects are common to all methods of administration, although they may differ in severity depending on how the drug is given:

• Pain and burning at the application site. In one study half of the men who injected alprostadil experienced some burning and pain at the injection site. (Such effects from the cream are mild to moderate in intensity.)
• Scarring of the penis (Peyronies disease), which is most likely to occur with injections.
• Sudden, low blood pressure. Symptoms include dizziness, lightheadedness, and fainting. If these symptoms occur, the man should lie down immediately with his legs raised.
• Priapism (prolonged erection). Possible with any method, but less chance with the MUSE system than with injections. If priapism occurs, applying ice for ten-minute periods to the inner thigh may help reduce blood flow. Erections that last four hours or longer require emergency care.
• Women partners may experience vaginal burning or itching. The drug may have toxic effects if it reaches the fetus in pregnant women, so men should not use alprostadil for intercourse with pregnant women without the use of a condom or other barrier contraceptive device.

In addition, each method has other specific side effects.

Injected Alprostadil. Injected alprostadil (Caverject, Edex) employs a very small needle that the man injects into the erectile tissue of his penis. About 80% of men describe the pain of administering the injection as being very mild. Edex is a newer and less expensive form of injected alprostadil. In one 12-month study of 894 patients, Edex injections achieved erections in 95% of attempts. There is some evidence that the agent may have long-term benefits on smooth muscles. Some men have even reported return to spontaneous erections after long-term use, although objective evidence has not confirmed these findings.

The drug should not be injected more than three times a week or more than once within a 24-hour period.

Specific reports of the severity of side effects using injections include the following:

• Pain and burning at the injection site. Half of men reported this side effect in one study. To help prevent this side effect, experts in one study recommended a lower starting dose of 2.5 micrograms with subsequent doses increasing by increments of 2.5 until an erection is achieved. In this study there were only two episodes of pain out of 138 injections. (Usually, patients start with a dose of 20 micrograms.)
• Priapism. Studies report that up to 4% of men using injection therapy experienced erections lasting more than four hours, but most cases resolve without treatment.
• Scarring (Peyronies disease). This occurs in almost 8% of men who use injection therapy for more than a year. Treatment can be resumed when the condition resolves.

In spite of its general success, self-injection therapy has a high dropout rate and is less likely to be used now that oral treatments are available. The primary reasons for dropping out are the following:

• Loss of interest in the procedure.
• Partner objection or relationship breakup.
• Cost.
• Spontaneous improvement in erections.
• Side effects (reported as being severe enough to withdraw by 10% of men in one study).
• Lack of effectiveness (14% in one study).

MUSE System. The MUSE system delivers alprostadil through the urethra. It works in the following way:

• The device is a thin plastic tube with a button at the top.
• The man inserts the tube into his urethral opening right after urination. (Urinating or urine leakage right after administration may reduce the amount of medication.)
• He presses the button, which releases a pellet containing alprostadil.
• The man rolls his penis between his hands for 10 to 30 seconds to evenly distribute the drug. To avoid discomfort, the man should keep the penis as straight as possible during administration.
• The man should be upright, either sitting, standing or walking for about 10 minutes after administration. By that time, he should have achieved an erection that lasts between 30 to 60 minutes. (If a man lies on his back too soon after administration, blood flow to the penis may decrease and the erection may be lost.)
• The erection may continue after orgasm.

Reported success rates have been around 50% but range widely. A 2001 study reported higher success rates with sildenafil (Viagra), and in another study, only 18% of men requested additional refills. Some experts believe that these less than optimal results may be due to the physicians failure to educate patients and their partners adequately about the procedure.

Specific reports of side effects using the MUSE system include the following:

• Burning in the urethra. Up to 31% of MUSE administrations result in a burning sensation in the urethra that can last five to 15 minutes. This pain is generally mild to moderate, however, and is not a primary reason for discontinuing.
• Penile pain. Some pain in the penis occurs in about a quarter to a third of cases; it is usually mild.
• Low blood pressure. About 3% of patients experience low blood pressure, which can cause dizziness or fainting.
• Drug interactions. Taking certain cold and allergy remedies may offset the effects of the MUSE-administered drug.
• Other side effects. Other side effects include minor bleeding or spotting, redness in the penis, and aching in the testicles, legs, and area around the anus.

The MUSE system should not be used more than twice a day and is not appropriate for men with abnormal penis anatomy.

Topical Cream. Alprostadil is being developed as a topical cream or gel (Topiglan, Alprox-TD). The cream is applied to the tip of the penis 15 minutes before intercourse. Studies are reporting an efficacy rate of 40% to 75% and no significant side effects, although some men report a temporary burning sensation at the application site. The consequences to the female partner are not known.

Injections Using Papaverine and Phentolamine

Until the introduction of alprostadil, the two drugs used for injection therapy had been papaverine (Pavabid, Cerespan) and phentolamine (Regitine). Adverse reactions are usually minor but include pain, ulcers, and prolonged erections (priapism), which sometimes require a needle to withdraw blood or another drug to reverse the process. In a 2000 study, a combination of these two drugs produced a much higher drop out than alprostadil alone or a triple combination of all three.

Navigation

• Introduction
• Risk Factors
• Lifestyle or Psychological Causes
• Physical Causes
• Prognosis
• Diagnosis
• Treatment
• Lifestyle Changes
• Medications
• Injections or Topical Treatments
• Other Treatments
• Natural Remedies

There are three oral medications approved for the treatment of erectile dysfunction: sildenafil (Viagra), vardenafil (Levitra), and tadalafil (Cialis). All three belong to a class of drugs called selective enzyme inhibitors. Sildenafil (Viagra), vardenafil (Levitra), and tadalafil (Cialis) block the enzyme phosphodiesterase-5 (PDE5). Blocking this enzyme helps maintain levels of cyclic guanosine monophosphate (GMP), a chemical produced in the penis during sexual arousal. Balanced levels of GMP causes the smooth muscles of the penis to relax and increases blood flow.

Good Candidates for PDE5 Inhibitors. PDE5 Inhibitors are a good choice for men at any age and in any ethnic group who are in good health and who do not have conditions that preclude taking it (such as the use of nitrates or alpha-blockers; see higher-risk candidates in this section.)

Effectiveness of PDE5 Inhibitors.

• Tadalafil (Cialis). Approved by the FDA in November 2003, tadalafil appears to take effect in 15 to 30 minutes. It is the only oral ED treatment shown to improve erectile dysfunction for up to 36 hours in most men. A randomized study of 2,102 men in the British Journal of Urology found that those nearly two-thirds of those receiving 20 mg reported successful intercourse attempts 24 to 36 hours after taking the drug.
• Vardenafil (Levitra). Extensive clinical studies have shown that vardenafil improves erectile dysfunction in up to 85% of men with the condition. It also has shown to be work well in diabetic patients and in those who have had a radical prostatectomy.
• Sildenafil (Viagra). Studies indicated that overall, sildenafil may help more than 70% of patients achieve sexual function, with results depending on indication conditions.

Studies indicate Viagra is safe and effective for many men whose erectile dysfunction is related to the following conditions:

• Hormonal problems or psychologically induced impotence. These men achieve the highest success rates (80% to 100%). Furthermore, in one study, among men with mild to moderate depression who responded to the drug, symptoms of depression eased in 76% of them.
• Stable heart disease, with symptoms responsive to drug therapy, but who are not taking nitrates.
• Controlled diabetes (type 1 or 2). Diabetes has been associated with a lower than average response to Viagra. Still, in a 2002 study over half of patients with type 2 diabetes achieved at least one successful sexual event.
• Controlled hypertension.
• Kidney conditions, including those that require chronic dialysis and kidney transplantation.
• Parkinsons disease. There is even some evidence that sildenafil may even have properties that improve depression and help brain functions (attention, memory).
• Mild to moderate congestive heart failure. (A randomized study in the March 8, 2004 Archives of Internal Medicine found that men with moderate congestive heart failure and ED can safely use sildenafil to improve their sexual function and overall quality of life, provided the men are not taking nitrates for their heart condition. In addition to exhibiting improvements in ED, the study participants taking Viagra also showed higher scores on depression screening exams. Other research has also suggested that Viagra is safe for this group of men and may even improve exercise capability.)
• Taking antidepressant agents that can cause sexual dysfunction, notably the popular serotonin reuptake inhibitors, such as Prozac.

Sildenafil may also help restore erectile dysfunction in some (but fewer) men who have had the following conditions or treatments:

• Treatments for prostate cancer. In men who have had radiation, advanced techniques, such as 3D conformal therapy, along with sildenafil offer the best chances for success (70% in one study). In men who have had surgery, sildenafil is most effective in younger men who were potent before surgery and who had bilateral nerve-sparing procedures. It is unlikely to be effective for men over 55 who had unilateral or non-nerve-sparing procedures. Starting first with alprostadil injections right after treatment, followed by sildenafil, may be the best approach and considerably improve success rates.
• Colon surgeries for cancer or inflammatory bowel disease.
• Spina bifida, a congenital defect of the spinal cord.
• Spinal cord injury. Sildenafil can be very effective in many of these men, especially those in which there is some erectile response and when the injuries are in the upper part of the spine.

Higher-Risk Candidates. PDE5 inhibitors aren't suitable for everyone. Those taking nitrate drugs for angina and/or alpha-blockers (other than Flomax 0.4 mg once daily) for hypertension and BPH should not take selective enzyme inhibitors. Men with the following conditions should not take PDE inhibitors without the recommendation of their physicians and even then should use them with caution:

• Severe heart disease, such as unstable angina, a history of heart attack, or arrhythmias. Sildenafil increases nerve activity associated with cardiovascular function, especially during physical and mental stress. Men with heart disease may benefit from an exercise test to determine whether resuming sexual activity increases their risk of a heart attack.
• Recent history of stroke.
• Hypotension (very low blood pressure).
• Uncontrolled diabetes.
• Uncontrolled hypertension.
• Taking anticoagulant therapy.
• Severe heart failure.
• Retinitis pigmentosa. (With this genetic disease, people do not produce phosphodiesterase-5 and do not respond to sildenafil.)

Administration and Effect. PDE inhibitors work only when the man experiences some sexual arousal. They are generally effective within 30 to 120 minutes when taken on an empty stomach. Sildenafil should be taken on an empty stomach; vardenafil and tadalafil may be taken with or without food. One study suggested that crushing a Viagra tablet and letting it dissolve under the tongue may speed up its actions. Its effects may last for several hours. PDE inhibitors should not be used more than once a day.

It should be noted that success rates increase with the number of attempts, so a man should not be discouraged if the drug does not work at first. In fact, one study suggested that it should be tried at least eight times using the appropriate dose. In such cases, success rates are over 80%.

Sildenafil (Viagra) can also be used together with injections, though side effects can be quite intense when the combination is used. A recent study in the Journal of Urology found that combo therapy with sildenafil (Viagra) and the testosterone gel Androgel may help restore sexual function in men with low testosterone levels who did not respond to Viagra alone.

Side Effects and Other Limitations. Common side effects of PDE inhibitors include flushing, gastrointestinal distress, headache, nasal congestion, back pain, and dizziness.

Effects on the Heart. There were early reports of fatal heart attacks in a small percentage of men taking sildenafil (Viagra). Notably, Viagra can cause drops in blood pressure that can be sudden and possibly dangerous when the drug is taken with nitrates, such as nitroglycerine, which are used for angina. Such effects have been fatal in some men. Other effects on the heart and blood vessels are not wholly known. For example, although some studies report improved blood flow to the heart, a 2001 study reported that the drug may excite the nerves associated with heart function. Nevertheless the most recent studies have not found a higher risk from Viagra for adverse heart events in men with heart disease who are not taking nitrates. In fact, some evidence suggests it may be safe for men with congestive heart failure who have the physical capacity for sexual intercourse. The bottom line is that no one taking nitrates, including the recreational drug amyl nitrate, should take sildenafil or any other PDE inhibitors. Caution is still warranted for men with severe heart disease, all evidence is reassuring on its safety for the heart.

Visual Effects. About 2.5% of men experience abnormal visual effects that include seeing a blue haze, temporary increased brightness, and even temporary vision loss in a few cases. Experts believe that visual disturbances are related to the inhibition of phosphodiesterase enzymes in the retina, but the effect appears to be temporary and insignificant, lasting a few minutes to several hours. Men at risk for eye problems who take sildenafil regularly should have frequent eye examinations with an ophthalmologist. Men should also see an eye doctor if visual problems last more than a few hours.

Seizures. There have been a few reports of seizures in men taking sildenafil. These are rare occurrences and it is not clear if there is any causal association.

Risk of Priapism. The drug poses a very low risk for priapism in most men. (Priapism is sustained, painful, and unwanted erection.) Exceptions are young men with normal erectile function who take sildenafil.

Interactions with Other Drugs. In addition to serious interactions with nitrates, it also may interact with certain antibiotics, such as erythromycin, and acid blockers, such as cimetidine (Tagamet). Patients should tell their physician about any medications they are taking.

Decrease in Effectiveness. Over time, sildenafil may lose effectiveness. A 2001 study found that after two years, 20% of patients had increased their dose to achieve the same effect, and 17% had discontinued sildenafil due to loss of efficacy. It is possible that these men were suffering from heart disease or other problems that was making their impotence worse. An earlier study found that 96% of men who had been taking sildenafil for two to three years remained satisfied with the treatment. In addition, a randomized trial of 282 men with erectile dysfunction found that sildenafil treatment is less effective in men with diabetes.

Angiotensin-Receptor Blockers for Men with Hypertension

Recent drugs known as angiotensin-receptor blockers (ARBs), also known as angiotensin II receptor antagonists are being used to lower blood pressure in men with hypertension. In one study after 12 weeks of treatment with an ARB called losartan (Cozaar), 88% of hypertensive males with sexual dysfunction reported improvement in at least one area of sexuality. The number of men reporting impotence declined from 75.3% to 11.8%. Other ARBs include candesartan (Atacand), telmisartan (Micardis), and valsartan (Diovan).

Testosterone Replacement Therapy

Testosterone replacement therapy may be helpful for some men, particularly those with hypogonadism. Forms of testosterone therapy include the following:

• Muscle injections using testosterone enanthate (Andryl, Delatestryl) or cypionate (Andro-Cyp, Depo-Testosterone, Virion). This has been the standard administration.
• Skin patch (Testoderm, Testoderm TTS, Androderm). Depending on the brand, patches may be applied to the skin of the scrotum every 24 hours or to the abdomen, back, thighs, or upper arm. In the latter case, two patches are required every 24 hours. Testoderm and Testoderm TTS may cause less skin irritation than Androderm.
• Skin gel (Androgel, Testim). At this time, the gel is applied only to the same parts of the body as the patch. A gel applied to the penile skin is being investigated for men with hypogonadism and erectile dysfunction. Pregnant women must avoid contact with the gel because theoretically the testosterone could harm the fetus.

Oral forms of testosterone are not recommended because of the risk for liver damage when taken for long periods of time.

Testosterone replacement is used or investigated in the following:

• Replacement Therapy for Hypogonadism. Testosterone replacement therapy may be effective in inducing puberty in adolescent boys with hypogonadism and may also be helpful for some adult patients with the condition. Either the skin patch or gel achieves normal testosterone levels in between 67% and 90% of men. The gel is proving to be more effective than the patch at improving sexual desire and well being. It may also be more effective in boosting energy and mood and increasing muscle mass and weight in men with testosterone deficiencies.
• Replacement for Older Men with Androgen Deficiencies. Some experts believe testosterone replacement therapy may be helpful for older men whose androgen (male hormone) levels are deficient.
• Testosterone in Men with Normal Levels. Testosterone therapy is not recommended for men with testosterone levels that are normal for their age group. One 2003 study did report that short-term (one-month) use of the patch in men with low-normal testosterone levels improved their response to sildenafil (Viagra).

There is some concern that replacement therapy may increase the risk for the following adverse effects, particularly in men with normal testosterone levels:

• Lower HDL (the so-called good cholesterol).
• Rapid growth of prostate tumors in men with existing prostate cancers. (Taking testosterone does not appear to increase the risk for prostate cancer, but experts remain concerned.)
• Lower sperm count.
• Possible cause of sleep apnea.
• Possible increased risk for polycythemia, an abnormal increase in red blood cells.
• Possible increased risk for benign prostatic hyperplasia.

In men with normal male hormone levels, replacement therapy also does not appear to improve bone mass or muscle strength.

DHEAS. Dehydroepiandrosterone sulfate (DHEAS) is a male hormone involved in the production of testosterone. Levels of this hormone decrease as a man ages. In a 2000 study, men under 60 years old with erectile dysfunction tended to have lower DHEAS levels than their peers. In one small study, those who took DHEAS for 16 weeks experienced some improvement in erectile dysfunction. It is available as a supplement but should not be taken without the recommendation of a physician. The long-term effects of this potent hormone are unknown but may be similar to those of testosterone replacement.

Experimental Agents

Oral Phentolamine. Phentolamine is an agent that has been used in injections for achieving erection. The drug blocks adrenaline (epinephrine), which dilates blood vessels. An oral form of phentolamine (Vasomax) has been developed that may be of some benefit for men with mild impotence. The drug is not as effective as sildenafil (Viagra) and it has more side effects. However, Vasomax works faster and it does not interact with nitrates. Studies suggest that it produces erections within 20 to 40 minutes in 40% to 50% of men with mild to moderate erectile dysfunction. Side effects include nasal congestion, headache, light-headedness, low blood pressure, tachycardia (increased heart rate), and nausea.

Apomorphine. Apomorphine (Spontane, Uprima), which is taken as a tablet under the tongue, causes a sexual signal in the brain to trigger an erection, although it is not an aphrodisiac. Studies report improved erectile function in 40% to 60% of men, with the better results occurring at the higher doses. High doses, however, also cause severe side effects, including nausea (in between 15% to a third of patients), yawning, fatigue, dizziness, sweating, excitability, and aggression. Apomorphine appears to be safe for men with diabetes or stable heart disease, and is well tolerated by men with high blood pressure. However, a recent European study of men with erectile dysfunction who had never received therapy found that Viagra worked better than apomorphine. It is not approved for use in the United States. It is available in Europe but not in the US.

Opioid Antagonists. Opioid antagonists, such naltrexone (ReVia), are used to help maintain abstinence in alcoholism. Naltrexone may be helpful for erectile dysfunction in men with inhibited sexual desire. A clinical trial is underway using naltrexone and yohimbe, the common alternative remedy for impotence. The most common side effect of naltrexone is nausea, which is usually mild and temporary. High doses can cause liver damage. The drug should not be administered to anyone who has used narcotics within a week to 10 days.

Intranasal melanocortin receptor agonist (PT-141). Findings presented at the 2004 American Urological Association Annual Meeting suggest that the nasal spray PT-141 may be an effective for treatment of erectile dysfunction. PT-141 works on the central nervous system instead of the vascular system. Unlike oral treatments, it does not require stimulation for erection to occur. It is currently undergoing clinical trials.

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• Lifestyle or Psychological Causes
• Physical Causes
• Prognosis
• Diagnosis
• Treatment
• Lifestyle Changes
• Medications
• Injections or Topical Treatments
• Other Treatments
• Natural Remedies

Because many cases of impotence are due to reduced blood flow from blocked arteries, it is important to maintain the same lifestyle habits as those who face an increased risk for heart disease.

Diet. Everyone should eat a diet rich in fresh fruits and vegetables, whole grains, and fiber and low in saturated fats and sodium. Because erectile dysfunction is often related to circulation problems, diets that benefit the heart are especially important.

Foods that some people claim to have qualities that enhance sexual drive include chilies, chocolate, licorice, lard, scallops, oysters, olives, and anchovies. No evidence exists for these claims, and eating large amounts of some of these foods, such as licorice and lard, can be dangerous.

Exercise. A regular exercise program is extremely important. One study reported that older men who ran 40 miles a week boosted their testosterone levels by 25% compared to their inactive peers. Another study found that men who burned 200 calories or more a day in physical activity (which can be achieved by two miles of brisk walking) cut their risk of erectile dysfunction by half compared to men who did not exercise.

A study in the Journal of the American Medical Association found that adopting healthy lifestyles changes improved sexual function in obese men (BMI > 30) with erectile dysfunction. After two years, a third of the study participants on the reduced calorie diet and increased exercise regimen regained sexual function.

Limit Alcohol and Quit Smoking. Men who drink alcohol should do so in moderation. Quitting smoking is essential.

Stay Sexually Active

Staying sexually active can help prevent impotence. Frequent erections stimulate blood flow to the penis. It may be helpful to note that erections are firmest during deep sleep right before waking up. Autumn is the time of the year when male hormone levels are highest and sexual activity is most frequent.

Kegel Exercises

The Kegel exercise is a simple exercise commonly used by people who have urinary incontinence and by pregnant women. It may also be helpful for men whose erectile dysfunction is caused by impaired blood circulation. The exercises consist of tightening and releasing the pelvic muscle that controls urination:

• Since the muscle is internal and is sometimes difficult to isolate, practice first while urinating. (Once learned, however, Kegel exercises should not be regularly performed while urinating because doing them at that time may eventually weaken the muscles.)
• Try to contract the muscle until the flow of urine is slowed or stopped. Attempt to hold each contraction for 10 seconds.
• Then release the muscle.
• Perform about five to 15 contractions three to five times daily.

It may be several months before the patient sees significant improvement.

Changing or Reducing Medications

If medications are causing impotence, the patient and physician should discuss alternatives or reduced dosages.

Psychotherapy and Behavioral Therapy

Even if erectile dysfunction is caused by a physical problem, interpersonal, supportive, or behavioral therapy can be of help to a patient during all phases of the decision-making process regarding possible methods of treatment. Therapy may also ease the adjustment period after the initiation or completion of treatment. It is beneficial to have the partner involved in this process. The value of sex therapy is questionable. In one study, 12 out of 20 men whose dysfunction had a psychological basis and who were advised to enter a sex clinic resisted sex therapy out of embarrassment or because they felt it wouldnt help. Of the eight who entered therapy, only one actually achieved satisfactory sex.

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• Introduction
• Risk Factors
• Lifestyle or Psychological Causes
• Physical Causes
• Prognosis
• Diagnosis
• Treatment
• Lifestyle Changes
• Medications
• Injections or Topical Treatments
• Other Treatments
• Natural Remedies

In spite of significant advances in treatment, only about 10% of men with erectile dysfunction seek medical help. To make matters worse, the physicians themselves are often embarrassed by the problem, even though it is almost always a treatable problem.

The cause of impotence dictates the mode of treatment. The first step is to define the cause, if possible, and then try the simplest and least-risky solution.

Before a certain treatment is prescribed, the following factors should be considered:

• Any pre-existing illnesses and medications.
• The degree of comfort with the treatment method.
• Partner satisfaction and safety profiles need to be considered. Experts strongly recommend that the patients partner be involved to help with any necessary sexual adjustment.

No matter what the treatment, embarking on a healthy lifestyle is the first and critical step for maintaining and restoring erectile function.

Treatment Choices

Medical and Surgical Treatments. Sildenafil (Viagra), the first effective oral agent for erectile dysfunction, has been on the market since 1998 and rapidly became the treatment of choice for most men with erectile dysfunction. However, in 2003, the FDA approved two other oral medications, vardenafil (Levitra) and tadalafil (Cialis), for the treatment of erectile dysfunction.

Those who cannot or choose not to take the drugs still have many other options, including the following:

• Medications inserted or injected into the penis.
• Vacuum devices.
• Intracavernosal injection therapy.
• Invasive procedures, such as penile implants or surgery (limited to those for whom other treatments havent worked and who have been carefully screened).

Ultimately, how successful the medical treatment is and how well it is accepted depends, in large part, on the mans expectations and how he and his partner both adapt to the procedure.

Psychotherapies. Some form of psychological, behavioral, sexual, or combination therapy is often recommended for individuals suffering from severe impotence, regardless of cause.

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• Natural Remedies

The physician typically interviews the patient about many physical and psychological factors. The patient must be as frank as possible for his physician to make a diagnosis. He should not interpret these questions as intrusive or too personal if he expects to obtain help. These questions are very relevant and important for determining the proper approach. Even when erectile dysfunction has a clear physical cause, relationships and psychological factors can also have an effect.

Medical and Personal History. The physician should take a medical and personal history and may ask about the following:

• Past and present medical problems.
• Medications or drugs being used.
• Any history of psychological problems, including stress, anxiety, or depression.

Sexual History. In addition the physician will ask about the patients sexual history, which may include the following:

• The nature of the onset of the dysfunction.
• The frequency, quality, and duration of any erections, and whether they occur at night or in the morning.
• The specific circumstances when erectile dysfunction occurred.
• Details of technique.
• The patients motivation for and expectations of treatment.
• Whether problems exist in the current relationship.

Interviewing the Sexual Partner. If appropriate, the physician might also interview the sexual partner. In fact, including the partner in the counseling process is proving to be an important component in making the best treatment choices.

Physical Examination

The physician should perform a careful physical exam, including examination of the genital area and a digital rectal examination (the doctor inserts a gloved and lubricated finger into the patients rectum) to check for prostate abnormalities.

Trials Using Treatments for Erectile Function

A useful approach is to administer a treatment for erectile dysfunction and then observe the response. Physicians now usually recommend a trial of sildenafil (Viagra) to test for an erection response after 30 to 60 minutes. This drug is replacing more invasive and expensive tests, such as an injection of papaverine or prostaglandin E1, medications that dilate blood vessels in the penis. They produce an erection in about 15 minutes.

After administering the treatment and waiting the appropriate amount of time, the physician then observes the erectile response, curvature of the penis, and response after erection, sometimes using an ultrasound scanner to assess blood flow.

Laboratory Tests

Blood Tests for Hormonal Abnormalities. Blood tests may be used to measure testosterone levels and, if necessary, prolactin levels to determine if there are hormone problems. The physician may also screen for thyroid and adrenal gland dysfunction. In addition, various specific tests for erectile dysfunction can be performed.

Tests for Medical Conditions That May be Causing Erectile Dysfunction. Evidence of other medical conditions should be sought, particularly hypertension, diabetes, atherosclerosis, and nerve damage.

Monitoring Nighttime Erections

Tests that monitor nighttime erections may be used to determine if the causes of erectile dysfunction are more likely to be psychological. Neither of the following methods is helpful in determining a physical cause for erectile dysfunction.

Snap-Gauge Test. The snap-gauge test monitors the mans ability to achieve an erection during sleep. It is a very simple test.

• When the man goes to bed, he places bands around the shaft of his penis.
• If one or more breaks during the course of the night, it provides evidence of an erection. In this case, a psychological basis for the erectile dysfunction is likely.

RigiScan Monitor. A more sophisticated and expensive device is the RigiScan monitor, which makes repetitive measurements of rigidity around the base and tip of the penis. This test is quite accurate but may fail to detect mild cases of erectile dysfunction.

Penile Brachial Index

The penile brachial index is a measurement that compares blood pressure in the penis with the blood pressure taken in the arm. Problems with the arterial flow to the penis can be detected using this method.

Imaging Techniques

Imaging tests may be used in certain cases, but they are expensive and often limited to younger men. Anyone considering these tests should have them done in a specialized setting by professionals experienced in their use.

Dynamic Infusion Cavernosometry and Cavernosography. Dynamic infusion cavernosometry and cavernosography (DICC) is usually only given to young men in whom some blockage of the penis or physical injury of the pelvic area is suspected. After an erection is induced with drugs, the following four steps are taken:

• The penile brachial index is taken.
• The storage ability of the penis is gauged.
• An ultrasound of the penile arteries is performed.
• An x-ray of the erect penis is taken.

Unfortunately, this test and other similar imaging techniques used to determine blood flow in the penis are currently not very effective or accurate in diagnosing and determining treatment.

Duplex Doppler Ultrasound. An ultrasound technique called duplex Doppler ultrasound may be useful alone or with sildenafil (Viagra) in determining the severity of condition and also to determine impaired blood flow through the arteries.

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• Natural Remedies

Temporary erectile dysfunction is very common and usually not a serious problem. Nevertheless, if the condition is persistent, psychological effects can be significant. Erectile dysfunction can have a devastating impact on a relationship and can cause extreme depression, which may become chronic if not treated. When a consistent pattern of sexual dysfunction extends over a prolonged period of time, a serious physical or emotional disorder may be present.

Persistent impotence may also be a symptom of a serious medical condition, such as heart disease, diabetes, hypertension, sleep disorders, or circulatory problems. For example, in a study of men who had suffered heart attacks, 75% of them had experienced erectile dysfunction on average 68 months before the heart attack.

Erectile dysfunction can also indicate the presence of injuries or the long-term effects of smoking, heavy drinking, or unhealthy diet.

Navigation Introduction Risk Factors Lifestyle or Psychological Causes Physical Causes Prognosis Diagnosis Treatment Lifestyle Changes Medications Injections or Topical Treatments Other Treatments Natural Remedies

Physical Causes A number of conditions share a common problem with erectile dysfunction--which is impaired ability of blood vessels to open and allow normal blood flow. Such conditions include diabetes, hypertension, coronary artery disease, kidney failure, peripheral artery disease, and stroke. Increasingly, researchers are studying the role of nitric oxide, which plays a major role in keeping blood vessels open, in all of these disorders. Some of these diseases, notably the following are highly associated with erectile dysfunction and have other factors involved in its development: Diabetes. Diabetes, for example, may contribute to as many as 40% of impotence cases. Between one-third and one-half of all diabetic men report some form of sexual difficulty. Blocked arteries and nerve damage are both common complications of diabetes; when the blood vessels or nerves of the penis are involved, erectile dysfunction can result. In June 2004, researchers reported on the first study looking at men with type 2 diabetes and symptomless heart disease. Their report in Circulation: Journal of the American Heart Association suggests that erectile dysfunction (ED) in men with type 2 diabetes may signal silent coronary artery disease (CAD). The study found that those who had silent CAD and type 2 diabetes were nine times more likely to have ED than diabetic men who did not have silent heart disease. High Blood Pressure (Hypertension). Erectile dysfunction is a very common problem in men with high blood pressure. More than 40 percent of men with erectile dysfunction have hypertension. The disease process is the major contributor to impotence, but many of the drugs used to treat hypertension also cause it. Newer anti-hypertensive agents, including angiotensin-converting enzyme (ACE) inhibitors and angiotensin-receptor blockers (ARBs) are less likely to cause erectile dysfunction. In fact, ARBs may be particularly effective in restoring erectile function in men with high blood pressure who suffer from impotence. Other Common Medical Conditions That Contribute to Erectile Dysfunction Parkinsons Disease. As a risk factor for impotence, Parkinsons disease (PD) is an under-appreciated problem. It is estimated that about one-third of men with PD experience impotence. The physical cause of PD-related impotence is most likely an impaired nervous system. Depression and lowered self-esteem also contribute to erectile dysfunction in these patients. Multiple Sclerosis. Multiple sclerosis (MS), which affects the central nervous system, also precipitates sexual dysfunction in as many as 78% of male patients. (Corticosteroids, which are common treatments for MS, may improve sexual function.) Other Common Medical Conditions. Other medical conditions that have been associated with erectile dysfunction in some cases include allergies, thyroid problems, lung disease, and epilepsy. Prostate Cancer and Its Treatments Advanced prostate cancer can damage nerves needed for erectile function. Prostate surgery and surgical and radiation treatments for prostate cancer can also cause impotence. A number of treatments for sexual dysfunction are available that may help some men. Prostate Cancer Surgery (Radical Prostatectomy). The first nationally representative study to evaluate long-term outcomes after radical prostatectomy concluded that impotence occurs far more frequently than previously reported. Those who have so-called nerve-sparing surgeries have better results than those whose surgeries affect the nerves around the prostate. Some evidence also suggests that sexual function rates might improve if the nerve-sparing prostate surgeries also spare the ducts that carry semen. Some studies suggest that impotence after prostate surgery may in part be due to injury to the smooth muscles in the blood vessels. Early treatments to maintain penile blood flow, particularly alprostadil injections, may helpful in restoring erectile function. In one study, men administered injections every other night for six months. They then started taking sildenafil (Viagra) three months after surgery. At six months, 82% of these men achieved penetration compared to only 52% of men who took Viagra only. The vacuum pump may serve a similar purpose as the injections. Radiation. Although it is generally believed that radiation poses a lower risk for impotence than does surgery, studies have reported similar rates after three years. Experts suggest radiation injures the blood vessels and so lead to erectile dysfunction over time. Some studies report a lower risk for impotence from brachytherapy, a radiation technique that involves the implantation of radioactive seeds compared to external-beam radiation. Still, there have been very few studies that have lasted more than two years. One five-year study reported a high long-term rate of impotence (53%) with brachytherapy, which is close to that of standard externally administered radiation. Early use of alprostadil injections and Viagra may help these men as well as those who had surgery. Drug Treatments. Prostate cancer medical treatments commonly employ androgen-suppressive treatments, which cause erectile dysfunction. Surgical Treatments that Affect Intestinal Tracts Surgery for Colon and Rectal Cancers. Surgical and radiation treatments for colorectal cancers can cause impotence in some patients. In general, colostomy does not usually affect sexual function. However, wide rectal surgery can cause short term or long-term sexual dysfunction. Total mesorectal excision (TME) may pose fewer risks than standard surgery. Sildenafil (Viagra) may help many men who experience this after surgery. Surgical Treatment of Inflammatory Bowel Disease. Rectal excision for inflammatory bowel disease (IBD) can cause impotence, but rates are low (2% to 4%). Sildenafil (Viagra) is very effective in restoring potency after IBD surgery. Operations for Fistulas. Surgery to repair anal fistulas can affect the muscles that control the rectum (external anal sphincter muscles), sometimes causing impotence. (Repair of these muscles may restore erectile function.) Treatments for Benign Prostatic Hyperplasia (BPH) Surgery and drug treatments for benign prostatic hyperplasia (BPH) can also increase the risk for impotence, although to a much lesser degree than surgery for prostate cancer. Between 4% and 10% of patients who have transurethral resection of the prostate (TURP) and open prostatectomy for BPH report impotence afterward. The risk is very low, however, in men who were functioning normally before surgery. Finasteride (Proscar) has been associated with impotence in between 6% and 19% of patients. Anti-androgen agents used to treat BPH can also cause erectile dysfunction. Medications About a quarter of all cases of impotence can be attributed to medications. Many drugs pose a risk for erectile dysfunction. Some authorities go so far as to say that nearly every drug, prescription or nonprescription, can be a cause of temporary erectile dysfunction. Among the drugs that are common causes of impotence are the following: Drugs used in chemotherapy. Many drugs taken for high blood pressure, particularly diuretics and beta-blockers. Most drugs used for psychological disorders, including anti-anxiety drugs, anti-psychotic drugs, and antidepressants, especially selective serotonin reuptake inhibitors (SSRIs). Newer antidepressants pose fewer problems. Anti-androgens, including drugs known as gonadotropin-releasing hormone agonists. They are used in prostate cancer and also for treating BPH. Drugs that sometimes cause impotence include: Older anti-ulcer medications (cimetidine). Anticholinergic drugs (including some antihistamines). Antinausea agents, particularly metoclopramide (Reglan). Antifungal drugs (especially ketoconazole). Physical Trauma, Stress, or Injury Injury to the Spine. Spinal cord injury and pelvic trauma, such as a pelvic fracture, can cause nerve damage that results in impotence. Other conditions that can injure the spine and effect impotence include spinal cord tumors, spina bifida, and a history of polio. Bicycling. Studies have indicated that frequent bicycling may pose a risk for erectile dysfunction by reducing blood flow to the penis. The greatest risk is in cyclers who sit upright while cycling. In addition, a report in the August 2004 Journal of Urology found that long distance cyclers may reduce their risk by riding a road bike instead of a mountain bike and by choosing saddles without a cutout. Note: Vasectomy does not cause erectile dysfunction. When impotence occurs after this procedure, it is often in men whose female partners were unable to accept the operation. Hormonal Abnormalities Hypogonadism (Testicular Failure). Hypogonadism in men is a deficiency in male hormones, usually due to an abnormality in the testicles, which secrete these hormones. It affects four to five million men in the United States. In addition to impotence, hypogonadism causes reductions in energy, sex drive, lean body mass, and bone density. Hypogonadism can be caused by a number of different conditions. Among them are the following: Disorders in the pituitary or hypothalamus glands. Malnutrition. Genetic factors. Myotonic dystrophy. Orchitis (inflammation of the testicles). Physical injury. Mumps. Radiation treatments. Exercise-induced hypogonadism. Only a few cases of exercise-induced hypogonadism have been identified in men. Some researchers believe, however, that certain athletes may be at risk, including those who began endurance training before full sexual maturity, have very low body weight, and have a history of stress fractures. Low Testosterone Levels. Only about 5% of men who see a physician about erectile dysfunction have low levels of testosterone, the primary male hormone. In general, lower testosterone levels appear to reduce sexual interest, not cause impotence. A 1999 study, however, suggests that testosterone levels are not an accurate reflection of sexual drive. Other Hormonal Abnormalities. Other hormonal abnormalities that can lead to erectile dysfunction include: High levels of the female hormone estrogen (which may occur in men with liver disease). Abnormalities of the pituitary gland that cause high levels of the hormone prolactin are particularly likely to cause impotence. Other, uncommon hormonal causes of impotence include an underactive or overactive thyroid or adrenal gland abnormalities. Varicoceles A varicocele is an enlarged (varicose) vein in the cord that connects to the testicle. Varicoceles are found in 15% to 20% of all men and in 25% to 40% of infertile men. When varicoceles occur in both testicles, they may contribute to hormone imbalances that cause erectile dysfunction.